medication overuse

27 July 2024

Another Weapon against “Rebound Headache”?

James Discoveries & Stats, Medications, Treatments 0

A major concern among migraine patients (and their doctors) is what we sometimes call “rebound headache” or “medication overuse headache”. The perhaps over-simplified idea is that taking “too much” medication may make your headache symptoms come back worse than ever, or more frequently.

But this explanation can be misleading, partly because the whole concept remains very controversial. Just which medications lead to more headaches? And if migraine medication “causes” migraine, what’s the treatment?

In spite of a lot of misunderstanding regarding these types of migraine attacks, the ultimate goal really isn’t to take “less medication”. The goal is – you guessed it – less migraine! If you’re taking a painkiller or migraine medication and your symptoms are worsening over time, it may simply be time to try something different. Even if you end up taking more pills, you may be able to start a trend of fewer and fewer headaches.

How so? For example, if you find yourself taking a painkiller or more every single day, and your headaches are only getting more severe as the months pass, not to mention side effects from the medication, one option is to try a daily preventative – something that has been tested properly specifically as a daily medication.

Though information is limited about certain types of medication for certain types of migraine, every once in a while a study comes out that prioritizes a certain kind of medication for a certain type of migraine – such as rebound or medication overuse. And that’s the case with a study published in the journal Neurology last month.

The drug is atogepant, a calcitonin gene-related peptide receptor antagonist, sold under the brand name QULIPTA (you can read more about atogepant here). It’s a preventative taken orally each day. And in spite of the fact that rebound type migraine attacks are notoriously difficult to treat, atogepant seems to make a significant difference.

In the study, patients took one or two dose per day (it was the same amount either way – 60mg total). Patients had 2-3 few days a month with migraine, and 3 fewer days with other medications. For those with medication overuse headache, that means about a 50% reduction in headaches for almost half of the patients. Many of the patients actually no longer met the official criteria for medication overuse headache by the end of the study.

The best results overall came for patients spreading out the daily preventative in two doses.

Once again, this is not a silver bullet that works for everyone. But the results are very good considering how difficult this type of condition can be to treat. Study author Dr. Peter J. Goadsby notes:

Based on our findings, treatment with atogepant may potentially decrease the risk of developing rebound headache by reducing the use of pain medications. This could lead to an improved quality of life for those living with migraine.
Dr. Peter J. Goadsby

This is one of those clinical trials that, although preliminary, can be useful immediately. Any medication showing positive results for medication overuse is worth moving up the list for those who are struggling with increasing headache and migraine symptoms.

9 December 2019

Discovery: A Link Between Opioid Overuse Pain and Migraine Pain

James Discoveries & Stats 0

Researchers at the University of Illinois have discovered a fascinating link between opioid overuse and migraine pain. This particular link is a good sign for new medications that are being studied now. Could these new medications help some migraine patients fight migraine and past opioid overuse at the same time?

PACAP levels - a key to ending your head pain? — PACAP and head pain

Senior author Amynah Pradhan explains what the team was trying to find out:

“Endorphin is an example of a peptide that signals the brain to give a ‘runner’s high.’ However, not all peptides signal for pleasant outcomes. Pituitary adenylate cyclase-activating peptide, or PACAP, is a peptide that can induce migraines in migraine-prone individuals. Because the overuse of opioids can lead to worse migraines, we wanted to determine whether opioid-induced pain changed the amounts of peptides in the brain and understand if pain from migraines and opioid overuse shared any peptides in common.
Amynah Pradhan [source]

As you might guess, the link was found. In this study with mice, PACAP was high in models with migraine pain and models with opioid pain. This could help to explain why opioid use leads to “rebound headache” for migraine patients.

Of course this helps us further understand migraine and how it interacts with opioid use, which can be helpful in some cases but often ends up being harmful. But even more interesting is that medication for migraine is being developed right now which targets PACAP levels. We’ve talked before about two medications being developed, ALD1910, and AMG 301, which target these peptides. This from Alder Biopharmaceuticals:

Alder is developing ALD1910, a preclinical monoclonal antibody (mAb) designed to inhibit pituitary adenylate cyclase-activating polypeptide (PACAP) for migraine prevention. PACAP has emerged as an important signaling molecule in the pathophysiology of migraine and represents an attractive novel target for treating migraine. ALD1910 may hold potential as a migraine prevention treatment for those who have an inadequate response to other therapies and could provide another mechanism-specific therapeutic option for migraine patients and their physicians.
[source]

Could it be that these new medications would especially help patients who have been regular opioid users in the past?

For more, see this from ScienceDaily: A new link between migraines, opioid overuse may be key to treating pain

4 December 2018

Medication Overuse – How much is too much?

James Information 0

Last time we talked about some of the different perspectives when it comes to medication overuse headache, or rebound headache. In layman’s terms, rebound headache refers to headache symptoms that are eventually made worse by the very medication that you’re taking to fight the symptoms.

For example, have you ever tried a medication that seemed to work well the first time, but after a while it didn’t work as well? Or you had to take more for it to work? Or you find that you’re taking it more and more often?

That could be an indication that the medication is making things worse.

Fewer pills? The question of “how much is too much” is very controversial. However, one perspective is that “more” is too much. In other words, every time you take a medication for migraine symptoms, the body depends just a little more on that medication (that’s not a technical term in this case – the point is that taking any medication makes it more likely that you’ll need more in the future).

Why may this perspective be helpful? Because instead of trying to take one less pill than some arbitrary measure (“only two per week”, for example, or “whatever my insurance company allows”), you’re aiming to take as little as possible. And this may, in the long term, pay off big time.

There are various approaches to “taking less”. Stopping cold-turkey (which sometimes requires “detox” at the hospital), stopping little by little. But in most cases, you’ll have to substitute something else – either a non-drug treatment (and there are many great options), and/or medication that is less likely to lead to rebound.

We’ll talk more about this concept. But in the mean time, consider changing your perspective a little. Don’t rely on your insurance company or doctor to decide how much is too much. Aim for less – or none. Even if you’re taking a little less this month than last month, that gradual decrease may mean huge improvements down the road.

1 December 2018

Rebound and Medication Overuse – New Perspectives

James Information 0

Rebound headache, medication overuse headache – these terms are bound to stir up controversy. How much medication is “too much”? How often is “too often”?

There are a few different ways to look at this. For example, there’s the official diagnosis, according to the International Headache Society’s classification. In that case, you have to be “overusing” for at least three months (and the definition of “overuse” is open to interpretation), and you have headache symptoms for at least 15 days a month.

One more pill? — How dangerous is one more pill?

This goes from a major problem to a severe problem – something like a drug addiction.

You can also look at it from a utilitarian point of view. What actually helps patients? Are there cases where a patient would be better off taking just a little more (not overdosing, of course!) instead of taking none of the offending medication? These things came up in a debate in 2016.

And which medications are dangerous, and which are not? Some list triptans very high on the list – others suggest they should be used more.

Finally, and perhaps most importantly, should we be thinking of this as a switch, or a scale? In other words, does medication overuse headache just “switch on” when you’ve taken one pill too many? Or is one more pill that much more of a problem?

Some are making the case that it’s much more of a scale, and that doctors are generally far too quick to increase the dose, to add another medication, or to skip non-drug treatments.

We’ll talk more about this next week, with some practical thoughts on the matter.

24 October 2016

Predicting: Will This Medication Work?

James Discoveries & Stats 0

Which would you prefer?

You walk into the doctor’s office, and the doctor offers you a medication that happens to interest them at the time.
You walk into the doctor’s office, and the doctor offers you the medication that works with the highest percentage of patients with your condition.
You walk into the doctor’s office, and the doctor checks your statistics and offers you the medication that is most likely to work for you.

I don’t know about you, but I would sure prefer #3. I would take a well-educated #2 if I couldn’t get #3. (And frankly, there are worse things than #1.)

Migraine Medication Predictions At this stage in migraine research, with a good specialist you’ll hopefully get a combination of #2 and #3 (and likely a pinch of #1). But researchers are trying to gather the information we need to offer more customized treatments.

As we gain the ability to gather more information about ourselves (e.g. FitBit and Migraine), the possibility of fitting the treatment more exactly to the patient is becoming a reality.

Perhaps a more immediate benefit is avoiding treatments that aren’t likely to work. Today, there are so many migraine treatments that a patient could spend a lifetime trying them – why start with treatments that probably won’t work because you’re a) a women or b) diabetic or c) suffering from a certain symptom?

A recent study in the USA studied responses from 8233 patients with episodic migraine to see which variables could predict whether or not an abortive treatment would work. Typical go-to medications for migraine are the various types of triptans.

So here’s the question – what types of things should a doctor know, that may predict whether or not a typical abortive treatment will work?

First, symptoms.

How intense is the headache?
How frequent are the attacks?
Does the patient suffer from cutaneous allodynia?
How intense are the symptoms overall?

Second, medical profile.

What comorbid conditions does the patient suffer from? Do they suffer from depression, for example?
Are they taking preventative medications (for migraine)?
Are they overusing any medications?

Finally, certain basic factors come into play, such as

Gender
Body mass index

These and other factors may help us better customize your treatment in the future.

In the mean time, the more information you can keep track of (don’t let it take over your life) the better. Keep in mind your medical history (and family medical history) as well, which can help your doctor a great deal.

To read the abstract of this study, go to Predicting Inadequate Response to Acute Migraine Medication: Results From the American Migraine Prevalence and Prevention (AMPP) Study from the October 2016 edition of Headache.